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SA2000-04-12

Coroner's Finding: BEST Todd

16y · Male·Internal haemorrhage due to closed chest and abdominal injuries sustained in mot…

Todd Best, aged 16, died from internal haemorrhage following blunt chest and abdominal trauma sustained when struck by a police vehicle while evading custody. He had been arrested for property damage, placed in the front…

systemcannabis
SAhospital2000-04-12

Coroner's Finding: RUSSELL Brian Edward

80y · Male·bronchopneumonia complicated by morphine toxicity

An 80-year-old man with terminal liver disease died from bronchopneumonia complicated by morphine toxicity following a medication administration error. A Graseby infusion pump was incorrectly set at 99mm/hour instead of …

palliative caregastroenterologymedicationproceduralmorphine
NThospital2000-04-10

Inquest into the death of Baby J

0y · Female·premature delivery; extreme prematurity

A 19-week pregnant woman was admitted for pregnancy termination due to maternal psychological concerns. Labour was induced with misoprostol, expecting foetal death in utero or delivery of non-viable remains. Instead, a l…

obstetricsmidwiferycommunicationsystemmisoprostol
SAaged care2000-04-07

Coroner's Finding: FALKENBERG Desmond Martin

73y · Male·dehydration and hyperthermia

A 73-year-old man with mild dementia resident in aged care wandered from the facility on a hot day (31°C+) while taking three medications with anticholinergic properties: pericyazine, haloperidol, and oxybutynin. These d…

geriatric medicinepsychiatrysystemdelayneulactil
SAmental health2000-04-07

Coroner's Finding: SANDERS Sandra June

42y · Female·salt water drowning

Sandra Sanders, aged 42, a detaineε psychiatric patient, died by saltwater drowning after absconding from Woodleigh House psychiatric unit on 3 September 1997. She had presented with major depression with psychotic featu…

psychiatrycommunicationsystemstelazine
WA2000-04-07

Inquest into the Death of Kenneth John Groth

47y · Male·Ligature compression of the neck (hanging)

Kenneth John Groth, aged 47, died by hanging in Casuarina Prison on 9 April 1998. He was a sentenced prisoner convicted of sexual offences, serving a 10-year sentence. His appeal was adjourned and legal aid was refused, …

psychiatrycorrectional healthdiagnosticfluoxetine
SAcommunity2000-03-13

Coroner's Finding: STRANGWAYS Kenneth Charles

34y · Male·aspiration pneumonia following seizure with concomitant global severe anoxic enc…

Kenneth Strangways, a 34-year-old Aboriginal man with post-traumatic epilepsy, organic brain damage from head injuries, alcoholism and psychiatric illness, died from aspiration pneumonia following a seizure. The death wa…

psychiatryneurosurgerycommunicationsystemanticonvulsant medications
WAhome2000-03-10

Inquest into the Death of Michael James Dwyer

30y · Male·acute combined heroin and alcohol toxicity; ingestion of alcohol and heroin

Michael James Dwyer, a 30-year-old man, died on 17 June 1999 at Royal Perth Hospital from acute combined heroin and alcohol toxicity. On 11 June, after returning from Melbourne, he consumed approximately one litre of gin…

emergency medicineintensive caredelayheroin
WAcommunity2000-03-07

Inquest into the Death of Neil Kingsley Rushton

Male·Head Injuries sustained from motor vehicle collision

Neil Kingsley Rushton died on 27 November 1997 after being struck by a motor vehicle whilst lying on Lyon Road, Wandi, Western Australia. He sustained fatal head injuries from the collision. The circumstances of how he c…

SAhospital2000-02-25

Coroner's Finding: STONEHOUSE Jarrod William (aka Scott)

23y · Male·aspiration of blood due to stab wound to trachea

23-year-old man with self-inflicted stab wound to neck presenting to emergency department while intoxicated and agitated. Ambulance noted 3cm laceration to midline trachea with minimal external bleeding. Registered nurse…

emergency medicinesurgerydiagnosticcommunicationalcohol
WA2000-02-11

Inquest into the Death of Sean Kevin Hayes

24y · Male·plastic bag asphyxiation

Sean Kevin Hayes, a 24-year-old male remand prisoner, died from plastic bag asphyxiation in his cell at Canning Vale Remand Centre in Western Australia on 20-21 August 1997. He had a history of psychiatric illness, previ…

psychiatrycorrectional healthsystemcommunicationstelazine
VIC2000-02-03

HINTERHOLZ Frederich

61y · Male·Head injuries from forklift tipover

A 61-year-old licensed forklift driver died when a Crown 35 SC TT 240 forklift tipped while the mast was extended, crushing his head. He was not wearing a seatbelt. Although the coroner found the employer had exemplary s…

proceduralsystem
WAmental health2000-01

Inquest into the Death of Steven Charles Indich

20y · Male·Ligature Compression of the Neck (Hanging)

Steven Charles Indich, a 20-year-old Aboriginal man with schizophrenia and a long history of psychotic symptoms, violent behaviour and substance abuse, died by suicide in Smith Ward at Graylands Hospital on 13 November 1…

psychiatryintensive caresystemhaloperidol
NTcommunity1999-11-24

Inquest into the death of Gary Peter Tipungwuti, Patrick Raymond Kerinauia, Noeline Pauantulura, John Gerard Orsto

Unknown·Four deaths: three by self-inflicted hanging, one by multiple injuries from fall

Four Aboriginal Tiwi Islanders died in 1998 from suicide by hanging (three cases) and by falling from a power pole (one case). The inquest identified widespread alcohol and cannabis abuse, domestic violence, cultural dis…

alcohol
ACT1999-08-05

In The Matter Of An Inquest Into The Death Of Ian Glen Bransby At Canberra On 14.2.98

31y · Male·extensive global cerebral hypoxia following prolonged asphyxia following attempt…

Ian Glen Bransby, a 31-year-old remandee with a history of substance abuse and depression, died from asphyxia following attempted hanging at Calvary Hospital on 14 February 1998. He had been remanded at Belconnen Remand …

psychiatrygeneral practicecommunicationsystemchlorpromazine
ACT1999-06-28

Inquest Into The Manner And Cause Of Death Of Mark Robert Watson

17y · Male·Cerebral ischaemia caused by hanging at Quamby Youth Detention Centre at approxi…

Mark Watson, a 17-year-old boy charged with assault, was detained at Quamby Youth Detention Centre. During his second remand in September 1996, after a failed hospital admission, he returned to the same unit where he had…

psychiatrypsychologysystemsupervision
VIChome1999-06-25

1997 DANDENONG RANGES FIRES

Fire exposure and carbon monoxide poisoning in a deliberately lit bushfire

The 1997 Dandenong Ranges fires killed three residents at Ferny Creek on January 21. Jennifer Lindroth (24), Graham Lindroth (26), and Genevieve Erin (50) died from fire exposure and carbon monoxide poisoning after shelt…

NThome1999-06

Inquest into the death of Clinton Leslie Kingsley

2y · Male·drowning

A 2-year-old Aboriginal boy drowned in an exposed septic tank at a remote community after plumbers removed concrete covers without installing replacements or notifying residents. The fibreglass lid's fastening screws had…

proceduralcommunication
VIChospital1999-03-29

JONES Eric

33y · Male·Postural asphyxia due to restraint (Posey Poncho vest)

A 33-year-old male admitted after drug overdose died from asphyxiation while restrained in a Posey Poncho vest. Successfully treated for overdose complications, he developed drug-induced delirium with agitation, promptin…

intensive careemergency medicineproceduralsystemmethadone
ACTcommunity1999-02-26

In The Matter Of The Death Of Warren Geoffrey Ianson

Male·Transection of the aorta with exsanguination caused by gunshot wounds to the mid…

Warren I'Anson died from gunshot wounds to the mid-back on 17 November 1995 during a police response to a mental health crisis. He had schizophrenia, recently experienced grief from his wife and friend's deaths, and was …

psychiatryemergency medicinecommunicationsystemdiazepam

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